Quality and Governance
Good governance is the foundation of high quality, safe and effective healthcare. It ensures there is a clear framework of communication and accountability, effective systems and processes, measures and evidence to drive improvement, and a culture of honesty, integrity and openness.
Good Governance
At King Edward VII’s there is strong commitment to the structure, processes and culture of good governance, led by a highly effective and experienced governance team. We support the hospital to provide the highest standards of quality care for patients in a safe, caring and professional environment. There are many areas we oversee and manage within the hospital: patient safety, risk management, audit and compliance, credentialing, health and safety, infection control and prevention, complaints management, management of policies, guidelines and procedures, regulation and legal issues, performance and outcome indicators and information governance.
Find out more about the high-quality care you can expect in this Independent Healthcare Providers Network video:
Statement of Purpose
The Statement of Purpose for King Edward VII’s Hospital Sister Agnes as required by the Care
Quality Commission (Registration) and (Additional Functions) and Health and Social Care Act 2008
(Regulated Activities) (Amendment) Regulations 2012 can be read here: King Edward VII’s Hospital Statement of Purpose
Patient Safety and Risk Management
The safety of patients in our care is paramount. We have the very best consultants, staff and facilities but all healthcare, like life, carries some risk so we minimise these in a number of ways. We have strong risk management systems that enable us to identify risks and issues and rectify them where able. We carry out regular audits, continually review and supervise housekeeping, the environment and catering services, encourage staff and patients to feedback on their experiences and have in depth reviews of our data to identify trends and issues. We have an incident reporting system where errors, issues or near misses are reported to allow us to review, learn and improve when we have unexpected occurrences. Find out more about our Patient Safety Partner.
We have a culture of openness and transparency and will always protect the trusting relationship we have with our patients by keeping them informed about their care and treatment, but also if things don’t go to plan. We comply with statutory Duty of Candour but it is inherent in how we work here at the hospital.
The hospital has a comprehensive risk register where significant risks are logged and managed with Board level oversight. We also have external scrutiny with assessments and regulatory inspections.
Infection Control and Prevention
We are proud of our zero incidence of MRSA blood stream infections or Clostridium Difficile. We have a reputation for cleanliness and infection control and will make every effort to minimise the risk of infection while patients are in our care.
Protecting You Against Infection
The hospital size enables us to closely monitor hygiene and infection control practices throughout the hospital. All ward patients have individual patient rooms with private en-suite which facilitates the potential of reducing infections.
Infection Control Team
Our hospital’s Infection Control Team, made up of a specially-trained, Master’s Degree educated senior nurse and skilled microbiologists, lead on screening patients for infection and also ensure the hospital follows strict guidelines around cleanliness.
In particular, we screen certain patients with risk factors and/or who are coming for certain procedures for MRSA prior to admission or on admission.
- All staff receive ongoing training in hospital hygiene and infection control best practice.
- Our in-house cleaning staff, available 24 hours a day, are trained by us to maintain a high standard of cleanliness. All rooms are cleaned daily and are deep-cleaned between occupancies.
- Hand hygiene is essential for everyone in the hospital. We ask all patients and visitors to use the alcohol gel dispensers throughout the hospital to clean their hands.
- Where possible we use single-use disposable equipment. In other circumstances equipment is cleaned, disinfected and sterilised in line with national protocols.
- We fully comply with guidelines and protocols issued by the Department of Health and the National Institute for Health and Clinical Excellence for the prevention and control of infection.
MRSA Screening
MRSA (Methicillin-resistant Staphylococcus aureus) is relatively uncommon, but can be present on the skin or in the nasal passages of healthy people. If it is not strictly monitored, isolated and controlled it can cause complications, for example with wound healing.
We screen certain patients with risk factors and/or are coming in for certain procedures for MRSA at pre-assessment or on admission. This is a quick and painless procedure in which a nurse takes a sample from each nostril using a cotton bud. The sample is sent to the laboratory and if MRSA is detected we can treat the infection before complications occur.
The results are available within 24-48 hours and those whose test shows they have MRSA bacteria on the skin will be contacted and given an ointment for the nose and a body and hair wash to use for five days.
The MRSA swab result is valid for four weeks.
Audit and compliance
The hospital has a continual audit programme in order to confirm that the best possible standards of care and service are consistently provided and, where there are any areas of improvement identified, act on these promptly. In addition we have an annual Patient Led Assessment of the Care Environment (PLACE) audit and in the last audit the results for Privacy, Dignity and Wellbeing fell above the national average.
We also submit data to the National Joint Registry, Public Health England, National Confidential Enquiry into Patient Outcome and Death, the Private Healthcare Information Network and The Care Quality Commission.
Patient experience and feedback
The hospital asks all patients to provide feedback on their experience. This feedback provides an invaluable opportunity for the hospital to know where care and services are doing well and where improvements are required.
Complaints
The hospital receives very few formal complaints; we pride ourselves on being responsive to an individual’s needs at the time and quickly rectifying any issues. However, like all healthcare providers we do have a complaints process that ensures we listen to patients, undertake investigations to establish facts and information and provide feedback. We take the opportunity to learn from formal complaint feedback and make improvements where required. Simply email complaints@kingedwardvii.co.uk or download our complaints leaflet:
Caldicott Guardian
The Caldicott Guardian advises on the ethical use of confidential information concerning staff and patients. King Edward VII’s Hospital’s Caldicott Guardian is Sarah Colebrook (Chief Nursing Officer).
If you wish to contact the Caldicott Guardian please email: Caldicottguardian@kingedwardvii.co.uk
Policies, Guidelines and Standard Operating Procedures
All organisations need a clear system of documenting their position on topics relevant to their area of business, to guide clinical and professional decision making and to clearly describe approved practices. This is done through publishing policies, guidelines and standard operating procedures which, where available, reflect current best practice standards, up to date research evidence and relevant legislation.
King Edward VII’s Hospital has a considerable number of policy and guidance documents, aligned with National Institute of Clinical Excellence (NICE) and other national body best practice guidelines to ensure the highest quality of cutting edge care.
The policy and guidance documents also assist with education and training and ensure that all staff are working towards common aims and objectives. The Governance team has an overall role in supporting the development and review of all Hospital policies, guidelines and standard operating procedures the audit cycle and staffs ongoing learning.
Safeguarding Assurance Statement
At King Edward VII’s Hospital, we are committed to safeguarding children, young people, and adults. We work closely with partner organisations to ensure the safety and wellbeing of all our patients.
We fulfil our statutory duties under the Children Act (2004), and the Care Act (2024) by maintaining robust safeguarding leadership. Our Chief Nursing Officer acts as the Executive Safeguarding Lead, supported by a dedicated Safeguarding Advisor and a Paediatric Nurse Advisor. Together, they oversee all aspects of safeguarding, including responsibilities related to the Prevent Duty, child exploitation, Female Genital Mutilation, and mental capacity.
Our Safeguarding Approach
- Staff training: All staff receive safeguarding training to recognise concerns and respond appropriately.
- Staff recruitment: We follow safer recruitment practices, including Disclosure and Barring Service (DBS) checks for all employees, consultants, and professionals with practicing privileges.
- Policies and governance: Our safeguarding policies are reviewed at least every three years, or sooner if national guidance changes. These policies are accessible to all staff via our electronic policy library.
- Monitoring and reporting: We have systems in place for staff to record safeguarding concerns electronically, enabling us to monitor activity, share learnings, and identify good practice.
- Oversight and assurance: Our Safeguarding Committee meets quarterly to review safeguarding activity, reporting to the Executive Quality and Safety Board and the Integrated Governance Committee.
Raising Concerns
If a patient, family member, or carer has concerns about safeguarding within the hospital, we encourage them to speak first with the nursing staff on the ward or department. Concerns will always be taken seriously and managed in line with our safeguarding procedures.
At King Edward VII’s Hospital, safeguarding is everyone’s responsibility. We are committed to maintaining the highest standards of safety, protection, and care for every individual who uses our services.
Our Enhanced Care unit
At King Edward VII’s Hospital, we are committed to providing the right level of care for every patient at every stage of their recovery.
Our Enhanced Care Unit (ECU) offers extra monitoring and support for patients who need more attention than is provided on a standard ward, but who do not require full intensive care. Our dedicated 4-bed ECU is staffed 24 hours a day, 7 days a week, by experienced critical care trained nurses and resident doctors, working alongside our team of expert medical consultants.
This means you will have continuous access to specialist care in a calm, supportive environment. The ECU is classed by NHS England as level 1+ care – a step down from a High Dependency Unit (Level 2) or an Intensive Care Unit (Level 3). It is designed to bridge the gap between ward care and more advanced critical care services, helping you recover in a safe and closely monitored setting.
In addition, our Enhanced Care Outreach Service supports patients across the hospital. This team of highly skilled nurses and resident doctors review patients daily on the wards to identify and respond early to any signs of deterioration, ensuring timely intervention.
Important Information: Our hospital does not provide Level 3 (full intensive care) services. If a patient’s condition requires this level of care, we will arrange safe and timely transfer to a nearby hospital with a Critical Care Unit.
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